Provider Demographics
NPI:1063238095
Name:SO, MARDON ELLEN
Entity type:Individual
Prefix:
First Name:MARDON
Middle Name:ELLEN
Last Name:SO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604-3017
Mailing Address - Country:US
Mailing Address - Phone:218-387-3040
Mailing Address - Fax:
Practice Address - Street 1:515 5TH AVE W
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604-3017
Practice Address - Country:US
Practice Address - Phone:218-387-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist